Editorial

Different Sites of Lower Limb Tendinopathy Different Loading Program

Stasinopoulos Dimitrios*
Department of Health Sciences, European University Cyprus, Cyprus


*Corresponding author: Stasinopoulos Dimitrios, Department of Health Sciences, European University Cyprus, Cyprus Musculoskeletal and Sports Trauma Research Centre, Diogenes Str Engomi, 1516, Nicosia, Cyprus


Published: 01 Mar, 2018
Cite this article as: Dimitrios S. Different Sites of Lower Limb Tendinopathy Different Loading Program. Sports Med Rehabil J. 2018; 3(1): 1027.

Editorial

Patellar and Achilles tendinopathy are two of the most common tendinopathy of the lower limb. Patients with tendinopathy mainly complain of decreased function and increased pain, both of which may affect daily activities. Diagnosis is based on palpation and reproducing pain with specific clinical tests as well as defining pain features (e.g. localized or referred pain). Although the symptoms and signs of tendinopathy are relatively clear, to date, no ideal management has emerged. A plethora of physiotherapy maneuvers have been recommended for the management of Achilles and patellar tendinopathy such as Electrotherapeutic (ESWT, Laser, Iontophoresis, Ultrasound) and Non-Electrotherapeutic modalities (Soft tissue techniques, Acupuncture and Exercise programs).
Nowadays, eccentric loading of the “problematic” tendon is the most commonly used conservative approach in the management of tendon injury [1]. A recently systematic review concluded that physicians should consider eccentric-concentric training alongside or instead of eccentric training [2]. A Heavy Slow Resistance (HSR) program is proposed in the tendinopathy rehabilitation of lower limb [3,4]. Based on the research findings, the HSR program can be proposed as an alternative to the Alfredson eccentric loading lower limb tendinopathy management. Recently, isometric training have been proposed to decrease and manage Patellar and Achilles tendon pain and start muscle-tendon unit loading when symptoms and especially pain limits the ability to carry out isotonic training [5-7].
The question that arises is if loading training is effective for all sites of Patellar and Achilles tendinopathy and for all patients with the above two referred tendinopathy? Research has found that different sites of achilles tendinopathy are managed with different protocols of eccentric training. For example, eccentric loading with dorsiflexion has positive effects for mid-portion achilles tendinopathy patients [1,8-11], but eccentric loading without dorsiflexion is effective on patients with insertion achilles tendinopathy [12]. Loading in HSR are carried out in the full range of motion of ankle joint for achilles tendinopathy. Therefore, HSR may not to be an effective treatment for insertion Achilles tendinopathy unless range of motion is changed. Furthermore, It is seems that HSR program is proposed for active young people.
Squat is an effective treatment technique when the patellar tendinopathy is at the most common site of pain in patellar tendinopathy, at the inferior pole of the patella [13-15]; however, no studies have found the effectiveness of such a loading program on other sites of patellar tendinopathy such as at the superior pole of the patella, at the midportion of the tendon and at the tibial tuberosity. Therefore, more studies are needed to determine the effectiveness of loading program at other sites of patellar tendinopathy.
Isometric evidence is currently applied in the management of the lower limb tendinopathy. Five repetitions of 45 second isometric mid-range quadriceps exercise at 70% of maximal voluntary contraction have been found to decrease patellar tendon (patellar tendinopathy at the most common site) pain for 45 minutes post exercise. The last was also associated with a reduction in motor cortex inhibition of the quadriceps that was related to patellar tendinopathy [16]. Three sets of five repetitions of isometric gastrocnemius contractions with maximum ankle plantar flexion and full knee extension combined with eccentric-concentric loading showed positive effect in mid-portion Achilles tendinopathy [6]. However, the parameters of isometric training are based on clinical experience and their effect on patients’ symptoms with tendinopathy of lower limb in different sites needs further research.
Writing this article it is not the intention of the author to increase the knowledge of physical therapist but to generate queries about why they do not use the similar treatment protocol for the rehabilitation of all lower limb tendinopathy. Further well-designed trials are needed to find the appropriate parameters of loading for each site of pain. It is believed that even if exercise training is found for the rehabilitation of all tendinopathy of the lower limb, this training will not be used as a sole treatment.


References

  1. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic achilles tendinosis. Am J Sports Med. 1998;26(3):360-6.
  2. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes. A systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013;43(4):267-86.
  3. Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP. Heavy slow resistance versus eccentric training as treatment for achilles tendinopathy: A randomized controlled trial. Am J of Sports Med. 2015;43(7):1704-11.
  4. Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009;19(6):790-802.
  5. Ark M. Exercise programs to decrease pain in athletes with patellar tendinopathy in season: A rct. Br J Sports Med. 2014;48:1-76.
  6. Stasinopoulos D. The effectiveness of eccentric-concentric training and isometric contractions on pain and disability in Achilles tendinopathy. A case report. Phys Ther Sport. 2017;28.
  7. Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. Br J Sports Med. 2014;48(7):506-9.
  8. Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic achilles tendinosis. Knee Surg Sports Traumatol, Arthrosc. 2001;9(1):42-7.
  9. Ohberg L, R Lorentzon, H Alfredson. Eccentric training in patients with chronic achilles tendinosis: Normalised tendon structure and decreased thickness at follow up. Br J Sports Med. 2004;38(1):8-11.
  10. Roos E, Engström M, Lagerquist A, Söderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion achilles tendinopathy-A randomized trial with 1-year follow-up. Scand J Med Sci Sports. 2004;14(5):286-95.
  11. Silbernagel K, Thomeé R, Thomeé P, Karlsson J. Eccentric overload training for patients with chronic achilles tendon pain - A randomised controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports. 2001;11(4):197-206.
  12. Jonsson P, Alfredson H, Sunding K, Fahlström M, Cook J. New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: Results of a pilot study. Br J Sports Med. 2008;42(9):746-9.
  13. Jonsson P, Alfredson H. Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: A prospective randomised study. Br J Sports Med. 2005;39(11):847-50.
  14. Dimitrios S, Pantelis M, Kalliopi S. Comparing the effects of eccentric training with eccentric training and static stretching exercises in the treatment of patellar tendinopathy. A controlled clinical trial. Clin Rehabil. 2012;26(5):423-30.
  15. Young MA, Cook JL, Purdam CR, Kiss ZS, Alfredson H. Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. Br J Sports Med. 2005;39(2):102-5.
  16. Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49(19):1277-83.